I can be reached at danduckworth@gmail.

com

123My research literally spanned hundreds, if not thousands of documents. In thebibliography I have captured those that were most useful. The bibliography will alsocorrespond to the soft copies that are available.

I wanted to leave this behind in an orderly fashion so that others who work with theorganization who need to learn about telemedicine, which is a relatively newconcept, will not have to start from nothing.

As with all of the deliverables and data referenced in this presentation, thebibliography and zip file will be downloaded to the folder “111” in “All Modules.”

4I wrote this paper at the outset of my internship with Byrraju. It was the best way Icould think of to discipline my initial research to catch myself up to speed beforearriving in Hyderabad. The paper is a good overview of the state of telemedicine foranyone who is knew to the field. Because I may attempt to publish this paper (orparts thereof) sometime in the future, I would appreciate if it is properly cited whenreferenced. If you desire to share it with someone outside the organization, pleasecontact me for approval first. See slides 11-14 for a discussion that includes themesfrom this research/writing.

5The village census was conducted in 2004. 144 villages were surveyed family byfamily. Data entry is suspect, and the census process itself is open to questions. Tomake any use of the data, I had to combine the documents into 5 district-level files. Ithen used Microsoft Excel to pull data from each separate file. The statistics Igathered are reviewed in a later section of this presentation. The raw statistics(tables, not charts) are available in an accompanying Excel spreadsheet.Unfortunately, because the calculations were drawing from files as big as 80 MB (inthe case of West Godavari district) I could not retain the original formulas that wereused to pull out the data (otherwise Excel would crash every time the formula tried toupdate the results). The titles of the tables, however, should be sufficient for thereader to understand what data was pulled. See slides 28-41 for a summary.

6The only information available for FY07 is at the aggregate level. The data cannot bebroken down into subcategories or by geography. As Oracle is implemented goingforward, it will be beneficial to build reports that allow the health care managers tosee specifically what the costs of investment and operation are, and also to compareacross districts to find abnormalities. See slide 42 for a summary.

The cost of setting of a village health center is data that was estimated by the financedepartment. Refer questions to it. See slide 43 for a summary.

The cash flow projections are included in the proposed model overview. I sat with thehealth care people to document what assumptions they made to estimate the futurecosts of the telemedicine model. I have a few concerns, noted in that documented,over the validity of some of the assumptions. Unfortunately, because past datacannot be “sliced and diced”, it is not as much help as it could be in projecting futurecosts and revenue. It was my questions regarding the assumed revenue stream thatsparked the ongoing study of villagers’ willingness to pay for telemedicine services.See slide 44 for a summary.

7There are three estimates for the costs of medicine. The first is taken from WestGodavari’s June report. Of course, it would be better to get the reports of all healthcenters and for many months to estimate the monthly cost of providing medicinesper village. By the time I realized such a report existed, it was too late to spend muchtime on a new round of data collection. There is also a project being conducted by agroup of Shiva Shivani interns, in which they have collected data on the costs ofmedicines for three villages in Rangareddi District. It was from their data that Iextracted the price per unit of the medicines that I used to compute the average costof medicines per month. See slide 45 for a summary.

The salary information was given to me by the finance department. See slide 46-47for a summary.

The age information was collected on my behalf by Arun Kumar and Venkata Rao,with the help of Vasundhari Alluri. See slide 48 for a summary.

8Villages I visited include:VandrumJuvvalapalemAllavaram KendramPoduruI-BhimavaremJallikakanaraKashevaremAnd several others whose names I failed to record

See slides 51-53 for a summary.

910My ideas on this are well-fleshed out in the white paper.

11My ideas on this are well-fleshed out in the white paper.

12Byrraju Foundation, both in verbal and written communication, offers the samepromise as the telemedicine field in general: lower costs, greater access, the same orbetter quality of health care.

Unfortunately, it also falls into the same trap: there is no proof of any of these things.For the Byrraju Foundation, that is okay. Telemedicine is very new program here, only6-8 months old. However, if the organization’s hopes to fulfill its mission to be aplatform by which other organizations can learn best practice, it should care deeplyto real evidence of the impact of its programs on cost, health, quality, etc. It shouldalso have data that proves its programs are the best option, at least for this area. Thatmeans collecting data on alternative models, including the one it is using currently.

13Too many organizations have “fallen in love with” technology, and they implement itjust because they can. More thought should be given, and more research conductedto prove, that telemedicine (in an form or fashion) is truly what it claims to be.

Currently, there is no way to know whether the Byrraju health model is the bestsolution to the health problems of Andhra Pradesh. The impact of the program istoday as much a conjecture as it was pre-implementation.

1415Data management is essential to good management, especially for an organization asbig as the Byrraju Foundation and whose headquarters is so distant from the on-ground operations. Without information on what is truly going on now, the managerscan only make decision based on a gut-feeling. Gut-feelings are sometimes right, butthey are sometimes wrong.

Speaking as someone who spent two years on a project to improve the informationmanagement of multinational agriculture, I cannot emphasize enough how importantit is to first clearly define the metrics and reports that management will actually useto make decisions. Whatever those are, that is what should be collected andprocessed – nothing more, and nothing less.

There is also a great opportunity now that Oracle has been implemented tostandardize the processes by which data is captured and reported on. Theorganization would be wise to learn this system and to handle as many of itsinformation needs as is possible through this system.

16The benefits of a willingness to pay study are many. The Foundation benefits withbetter information to make management decisions, and with which to convincedonors that its proposed model is financially sound. If a paper is published, it alsoenjoys the limelight of a broad audience that will learn about its programs as theylearn about the study’s conclusions.

Professor Ravi Anupindi (University of Michigan) and the research community alsobenefit, precisely because there is little to no quality research published in the threeareas here mentioned. I am confident that a paper that addresses these threesubjects will be well-received and widely circulated among the telemedicinecommunity.

17My time in Hyderabad has been largely focused on preparing for the study. I hopethat the information herein reported is useful to the study design.

18This is a side comment. The entire internship I have been thinking of a relatively basicconcept. When we say “sustainable” in terms of finances, we mean revenue meetscosts. When we say “self-sustaining” we mean that revenue is generated from withinthe system by charging a fee to the consumer. When we charge a fee to theconsumer, we automatically decrease the optimal volume of transactions. In the caseof health care, that means that charging a fee automatically creates a population thatwill not receive the service because it cannot afford it. Therefore, when we putforward “sustainable” as our goal, we should also recognize that we are sacrificing“universal” as another goal.

19Another side comment. There may be ways to blend “sustainable” and “universal”. One suchway is through price discrimination: charging patients according to an income scale wherethe poorest are not charged at all. So long as the “wealthier” (in relative terms) areovercharged by enough, their fees can subsidize the lost fees of the poorest.

Also, something that was mentioned by the villagers time and again is the income volatilityassociated with being a day laborer. They simply cannot say for certain what money will beavailable in the future. If Byrraju charged a monthly access fee as opposed to a fee-for-service, would this help smooth out the costs of health care for day laborers?

Also, I believe there is a great opportunity to generate revenue from personal use of thecomputer/internet setup. If Byrraju focuses on creating demand for personal uses (email,browsing, even job-related functions), it may be able to generate enough revenue tosubsidize the costs of health care for the poorest. Right now is postulated that the internetwill be made available for free as a means of helping people get comfortable with thetechnology. This may be a worthy goal, but I think a better goal is to use this opportunity togenerate revenue.

Organizational alternatives. Could nurses be better trained to reduce the demand fordoctors’ services? This would limit the number of doctors needed in the new model. CouldByrraju coordinate better with existing health care providers, training them to do certainfunctions well (well enough that Byrraju does not have a need to provide redundant services)while Byrraju focuses more on services that can be easily accomplished throughtelemedicine? Could there even be partnerships created with local providers much like HMRIpartners with district hospitals?

20The Foundation has two conflicting personalities. On the one hand, it has themanagement personality that wants to move forward with new ideas now. On theother hand, it has the research personality that wants to be a platform by whichothers can learn best practices. As far as telemedicine goes, if the research is going tobe done in a way that it truly demonstrates the impact of telemedicine on cost,quality, and access in comparison with the next best alternatives, then the brakesneed to be applied to the current plans to implement the new model by year end.The Foundation is in a wonderful position right now to do the kind of systematicresearch that the research community has been calling for (unsuccessfully) for thepast 10 years. It is my opinion that the good to be gained by doing the research theright way is worth far more than the good to be gained by moving full steam ahead.

21I am not an expert in research design, and neither are the managers at the ByrrajuFoundation. But there are plenty of such experts who have spent their entire careersperfecting this science who would be glad to join with the foundation to design andimplement such research. The Foundation should locate the top telemedicineresearch institutes in the world and should begin talking with them about whatresearch could be conducted and what faculty at that particular school would beinterested in participating. For example, it could start by contacting the TelemedicineResource Center at the University of Michigan Health System(http://www.med.umich.edu/telemedicine/).

2223This has been a wonderful opportunity to gain first-hand experience in a number ofdifferent areas, listed above. India is many different things, and to most people in theU.S. it is still very much a mystery. I now have a much clearer picture of what Indiareally is, and what it means when we talk about India as an emerging economy, high-tech hub, and developing country, and I now know what India’s cities and villages arelike (most Americans have only seen her cities and cannot comprehend what villagelife really means). I have read many statistics from the WHO, the World Bank, the UNthat talk about those people in the world that live on less than US$1/day. Now I havemet them (I know, because I have asked them how much they and their spouses earnand how many people they take care of with that income). I know what thatpopulation eats and drinks, what their homes look like, what their schools andhospitals are like, what their outlook on life is like. This has been very valuable.Moreover, to do this while working with a leader in nonprofit management likeByrraju has also given me the opportunity to see how nonprofits can leverage bestmanagement practices to accomplish their missions.

24Coming from the U.S., the internship experience can be very frustrating, especially inthe first few days. It should be clearly laid out what the logistics will be for the firstfew days. Also, a packet should be given to interns BEFORE THEY ARRIVE so that theycan navigate those first few days.

25This slide is just an example of what might be done. The point is simple. Too muchtime is lost in the first 2 weeks. A well-planned regiment should be implemented thatwill integrate the intern as quickly as possible into the work of the organization.Personally, I think intern projects should not be stand-alone projects that only he orshe is responsible for. I would much prefer to work on a project that started before Iarrived and will finish after I leave, but to be given a sub-project(s) within the largerproject that will help the existing team to meet its overall objectives and deadlines.There is a danger that this kind of work, if not properly planned and managed, couldbecome grunt work (making copies, etc.). Nevertheless, if well planned and managed,it will create the opportunity for the intern to produce something that is immediatelyand completely relevant to the work of the organization and avoid the possibility thatinterns’ work will either miss the mark and/or be put forgotten in the fuss over whatthe organization is actually working on at the very moment.

2627What is the population we are trying to serve?

28What is the population we are trying to serve?

29What is the population we are trying to serve?

30Can the population afford health care by telemedicine?

31Can the population afford health care by telemedicine?

32Can the population afford health care by telemedicine?

There looks to be a problem with the “All” bar on this slide, though the formulas wereaccurate. It seems like it should be closer to WG’s 1.6, though not necessarily higherthan it.

33What health facilities does the population currently patronize?

34What health facilities does the population currently patronize?

35What health facilities does the population currently patronize?

36What health facilities does the population currently patronize?

37Is the population prepared to deal with the technology associated with telemedicine?

38Is the population prepared to deal with the technology associated with telemedicine?

39Is the population prepared to deal with the technology associated with telemedicine?

40Is the population prepared to deal with the technology associated with telemedicine?

41424344454647A common argument at the Byrraju Foundation in favor of the telemedicine model isbased on the age and salary of the doctors. Management fears that the doctors,many of whom are retirement age when they sign on with the foundation, with retireen masse and the foundation will struggle to replace them. It fears that the low pay(relative to alternate positions in cities) and the high burden of travel (traveling tomultiple villages) will make it difficult to continually restaff. The numbers in this slideand the previous two slides reinforce that argument.

48HMRI employs 3 physicians for a four hour shift from 4-8pm. Management feels thatthe capacity of its doctors is much higher than what is shown here because theprogram is new and there are not enough patients to maximize efficiency. Of course,the question must then be asked, why employ 3 doctors instead of just 2 or 1 untilthe time comes that you need more?

49I designed a simple study in which 5 villages were randomly selected (restricted toEast and West Godavari districts, for management purposes). The nurse thenrecorded over three days the length of each visit. These numbers could be used toestimate how many doctors will be needed given the average time of a patientconsultation.

5051My main concern here is whether the nurses can handle the technology. Both times Ihave been out to the villages with a technical person, there have been serioustechnical problems that even he was unsure of how to deal with. Can the nursesreally be expected to cope with technical issues that are sure to arise? Neither theAshwini model or the HMRI model places any of the technology burden upon thenurses, but instead staff a technician who is there during the consultation along withthe nurse.

52The HMRI doctors are the only ones who have direct experience with primary care bytelemedicine. Their opinions were informative. They felt completely comfortable withtelemedicine in terms of the quality in 80% of the cases, but said 20% of the casesthey could not treat and had to refer the patients to come back to the hospital duringthe daytime when a doctor could see them in person. In the 80% of cases they candeal with, they said quality does not diminish at all with the telemedicine. When I askthem what the most significant gain to the patient is, they emphatically say that it isthe after-hours access. It seems that telemedicine is not seen as a value of its own,but merely as a means of extending the current health services. In other words, theyare not delivering any service that the patient couldn’t get otherwise, they are simplydelivering those same services at different hours.